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March2008

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Psychosis and PlaceDana March1, Stephani L. Hatch2, Craig Morgan3, James B. Kirkbride4, Michaeline Bresnahan1,Paul Fearon5, and Ezra Susser1,61Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY.2Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London, United Kingdom.3Department of Health Service and Population Research, Institute of Psychiatry, King’s College London, London, UnitedKingdom.4Department of Psychiatry, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom.5Department of Psychological Medicine, Institute of Psychiatry, King’s College London, London, United Kingdom.6New York State Psychiatric Institute, New York, NY.Accepted for publication April 29, 2008.One important line of epidemiologic inquiry implicating social context in the etiology of psychosis is theexamination of spatial variation in the distribution of psychotic illness. The authors conducted a systematic reviewof evidence from urbanicity and neighborhood studies regarding spatial variation in the incidence of psychosis indeveloped countries since 1950. A total of 44 studies (20 of urbanicity and 24 of neighborhood) were culled fromthree databases with similar time frames: Medline (1950–2007), PsychInfo (1950–2007), and SociologicalAbstracts (1952–2007). With a special emphasis on social factors potentially relevant to etiology, the authorselucidated contributions, limitations, and issues related to study design, measurement, and theory. Evidence fromboth arenas supports a possible etiologic role for social context. Studies of urbanicity indicate that early-lifeexposure may be important; dose-response relations, spatial patterning of schizophrenia, and interactions withother factors may exist. Neighborhood studies indicate heterogeneity in rates, hint at spatial patterning ofschizophrenia, and offer intriguing evidence implying more proximal social (as opposed to physical) exposures.The authors encourage the exploration of social pathways engaging theory, methodological advances, and thelife-course perspective. They also propose a conceptual shift from studies of spatial variation in outcomes toresearch addressing the etiologic effect of exposures shaped by place as a reservoir of risk or resilience.geography; incidence; psychotic disorders; residence characteristics; schizophrenia; social environmentINTRODUCTIONAccumulating evidence implicates soci al context in theetiology of psychosis. One important line of epidemiologicresearch pointing to a potentially causal role of social con-text is the examination of spatial variation in the distributionof psychotic illness. Such investigations have a rich history,in which social theory featured prominently in the first halfof the 20th century. Eclipsed for a period of time, interest inthe etiologic role of social context has been revived (1), anda new era of research has begun, stimulated in part by meth-odological advances and studies of migration and race/eth-nicity (2). However, more recent studies have beensomewhat disconnected from potentially enriching socialtheoretical perspectives that shaped earlier investigations.As recent work has indicated (3), integrating methodo logi-cal advances and social theo ry with the life-course approach(4, 5) can help in unraveling the meaning of important find-ings, such as the spatial distribution of psychosis. Towardthat end, we conducted a systematic review of evidence re-garding spatial variation in psychosis. Here we present ourfindings and critically discuss their implications.We first sketch the history and current relevance of classicresearch investigating the spatial distribution of psychosis,and follow it with a synthesis and interpretation of incidencestudies carried out in developed countries since 1950. Withan emphasis on social factors potentially relevant to etiol-ogy, we elucidate contributions, limitations, and issues re-lated to study design, measurement, and theory. Finally, inCorrespondence to Dana March, Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street,New York, NY 10032 (e-mail: [email protected]).84 Epidemiol Rev 2008;30:84–100Epidemiologic Reviewsª The Author 2008. Published by the Johns Hopkins Bloomberg School of Public Health.All rights reserved. For permissions, please e-mail: [email protected] 30, 2008DOI: 10.1093/epirev/mxn006Advance Access publication July 30, 2008order to increase understanding of the etiologic role of so-cial factors, we encourage movement from analyses exam-ining the spatial distribution of outcomes to analysesexamining places as exposures—from space to place.HistoryAttempts to characterize the spatial distribution of psy-chosis have produced a rich history of empirical research. Inthe United States, these efforts can be traced back to thesixth decennial Census, conducted in 1840 (6). Thoughplagued with methodological problems, notorious errors,and misinterpretations later exposed by Edward Jarvis (7),it constituted the first attempt to enumerate the ‘‘insane’’ inthe general population. Subsequently, Jarvis himself con-ducted a survey (8) marking the beginnings of descriptivepsychiatric epidemiology in the United States (9). Later inthe 19th century, other researchers put forward environmen-tal conditions such as climate, meteorologic phenomena,and topographic features to explain the purported spatialdistribution of insanity (10). Around the turn of the century,however, the emphasis on the physical environment began toshift to the social environment, and classifications of psy-chotic disorders began to emerge (9, 11).The first half of the 20th century witnessed several sem-inal contributions to our understanding of the social andgeographic distribution of psychosis. In 1932, O¨degaard(12) demonstrated a doubling of rates of first hospital ad-mission for psychosis among Norwegian migrants to Min-nesota, as compared with native Minnesotans and withNorwegians living in Norway. This work provided a founda-tion for investigations of migration and psychosis by gener-ating several testable hypotheses to explain this pattern offindings, including selective migration, dismissed only re-cently as a generally applicable explanation (13).Several years later, Faris and Dunham (14) publishedtheir classic ecologic study of psychosis in Chicago, Illinois ,Mental Disorders in


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